You know, working in the emergency department isn’t easy. An understatement, right? We all love the people and the medicine. We don’t, however, always love the uncertainty of what might roll through the ambulance doors. In small town Blair, Nebraska, one might say it’s even more demanding on a physician. In our rural, newly certified Level III trauma center, our role is different than that at a Level I facility. When we have a trauma or high risk patient come through our doors, we stabilize and ship. Stabilizing may be the easiest of our duties. Some days the helicopter won’t fly due to weather or the ambulance may be at least 45 minutes out by ground. During this time, we have a patient that may be stable or failing. We hear phrases like “time is muscle” or “time is brain.” Well, in my book, time is time. Some days it goes too fast and others I sit and watch the second hand slowly turn circles, like it’s stuck in pudding.

We don’t have specialists 24 hours at our facility. They come throughout the week for their 4-8 hour clinics and then head back south, a long 45 minute drive away. The majority of the time the facility is covered by us, the PCPs of Rural America. There are nights when I have sat in the ER wearing an over abundance of hats — the emergency physician, the hospitalist, cesarean section provider on call. Those nights I am strategically planning, “so if my OB walks in with an abruption, whom will I call to take my ER shift for an hour so I can go back to the OR with mom and baby?” It sounds scary, crazy, and maybe one might even classify it as “poor medicine.” But the reality is, it’s our norm. Rural areas are understaffed, and the physicians and medical professionals that make up the team better know what they are doing, be level headed, and know how to work together.

I have had to call a partner in for ER coverage for a 1-2 hour window while I complete a delivery. When I can’t find someone, I have had to do my best and utilize whom I can to keep me rolling. I have had to rush back and forth from laceration repairs, to the labor and delivery suite, to Med-Surg for medication changes, to the ER for an incoming stroke, and on and on and on. We are it.

I will never forget the day that there was a code blue called to the delivery rooms. I ran from my clinic to the hallway. I jumped on what seemed to be the slowest elevator to head to the second floor labor and delivery suite. You would have thought time stopped. I used that time to quickly recite my NRP skills in my head, mentally preparing. I finally arrived. In the hallway, I had to weave through a handful of people that included supervisors, radiology techs, lab techs, everything our small hospital had to offer. When I stepped in the suite, I saw a mom lying in bed with grimace and concern spread across her face. I quickly glanced to the other side of the room, where I see the Panda warmer and a macrosomic infant lying still, cyanosis taking over. The respiratory tech quickly went to the airway and I placed myself at the trunk where I expeditiously placed an IO for epinephrine to be given. CPR was in full progress with compressions being delivered by my partner. When I looked up, there was our scheduled ER physician for the day, sitting on a stool at the end of the bed delivering a placenta that belonged to the grief stricken mother. The female emergency physician was calmly consoling her and letting her know all would be ok. As we pushed forward with NRP skills, phone calls were being made, teams were ever so brilliantly shouting out ideas to help keep this infant alive until Children’s Hospital ground crew team could arrive. After 45 minutes of CPR, the crew arrived, the baby was pink and transferred over to their care. It was just last month that I saw that little boy in my clinic for his one year exam. His provider has since left and the mother thought it only right to transfer care to the next physician at the bedside performing CPR that day. The tears I shed after I walked out of that one year well child check were of happiness, and the memories of emotional exhaustion from that day.

Our facility is full of patients that each have their own story. As a physician in such a small community, I am able to hold stories within my heart that entail clinic patients, laboring patients, newborns, cesarean sections, and best of all emergency patients. We do it all, and the families of this community thank us for our hard work. Until the next emotionally exhausting day, thanks for listening.

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